Making sense of HIV/AIDS in South Africa: Issues in HIV prevention

1. Making sense of HIV/AIDS in South Africa: Issues in HIV prevention Centre for AIDS Development, Research and Evaluation www.cadre.org.zaWarren Parker • warren@cadre.org.za

2. Variations in antenatal HIV prevalence in Africa

3. HIV/AIDS in South Africa • South Africa has a population of 45 million and a diverse economy that has wide polarities between rich and poor • Majority of people are poor as a product of under and unemployment, but there is a highly active economic sector including mining, manufacturing and industry that is competitive globally • Approximately 4.5 million South Africans are HIV positive - amongst the highest total number of people living with HIV in any country worldwide • HIV affects all age groups, race groups and economic strata • Mainly heterosexual, very little IDU, generalised • Female risk is exacerbated by factors related to sex (biological vulnerability), gender (power differentials)

4. Population-based HIV prevalence, 2002

5. Antenatal HIV prevalence over time

6. Antenatal prevalence in <20 • Antenatal HIV prevalence amongst youth has remained much the same over the past four years

7. Disproportional effects on females • Biological factors increase female risk • Population-based studies show high prevalence, and disproportional effects on young females (2004) Males 15-19 2.5%Females 15-19 7.3%Males 20-24 7.6%Females 20-24 24.5% • Teen pregnancyrates have increased (1998/2004)

8. But, progress in condom access Increase in perceived ease of access• 2000, males and females 15-30, 75%• 2002, males and females, 15-24, 95%

9. And increased condom use • Increased public sector procurement • Demand-based logistics system, widespread access (including commercial and social marketing availability) • Quality control of product • Progressive increase in reported last intercourse condom use• 1998, DHS, females, 15-19, 21.2% (unmarried partner)• 2000, BAC, males and females, 15-30, 52%• 2002, NM/HSRC, females 15-24, 46.1%; males, 57.1%• 2003, RHRU, females 15-19, 55%; males, 57%

10. Factors underpinning high prevalence in South Africa (1) • HIV/AIDS response led by left wing health NGOs prior to 1994 (including ANC) • Comprehensive national AIDS plan in place pre-1994 • New government slow in implementing systematic response • NGOs marginalised by shifts in funding to bilateral model - many NGOs collapsed • Naïve positions adopted on AIDS including debates about HIV causality, failure to move efficiently to address mother to child HIV transmission, provision of ARVs (legal pressure by the TAC shifted policy) • Some systematic response – efficient condom logistics, increased access to voluntary counselling and testing

11. Factors underpinning high prevalence in South Africa (2) • Rapid growth in prevalence, and high current levels of HIV mean there is a very high average risk of infection through sex • Consistent condom use hasn’t been widely promoted, and consistent condom use is difficult • Mobility, migration, urbanisation and poverty exacerbate the epidemic • High turnover of sexual partners, late marriage – relationships unstable • Median age of first sex is 18, but highest risk of infection occurs in the over 20 age group • High levels of violence against women - unemployment, alcohol abuse, inadequate justice system

12. Approaches to understanding behaviour • Cognitive approach assumes that that:• learning is an interactive process• knowledge is objective• ideas can be communicated in a linear way - ie. from sender to receiver in such a way that meaning is easily shared. • Constructivist approach recognises that there is a relationship between the individual and his/her context• knowledge is subjective• communication is multifaceted • Humanist approach assumes that people have a desire to learn• knowledge is seen as a resource that can be sought out• communication is a multifaceted process

13. Cognitive approach • Centers on the individual and assumes that individuals can mitigate risk through making choices about their sexual practices (eg. when, where, with whom, how, how safely) • Assumes that agency lies with the individual • Assumes that knowledge and and the ability to act on knowledge (self-efficacy) are closely related • Assumes that risk is purely related to individual behaviour

14. Cognitive approach to sexual behaviour • Assumes sex is a rational activity and overlooks the heightened emotional states of sexual activity • Fails to address the fact that sex occurs with a partner who may determine when and how sex might occur • When applied to sexual behaviour it overlooks power relations that are a product of gender power differences as well as power embedded in cultural values placed on age, differences in economic power, in institutional power, in physical power • Assumes behaviour change is a consistent state • Overlooks structural vulnerability – for example, labour migration breaks up families, poverty creates inequality, inadequate policing and justice systems, inadequate rights frameworks

15. Limits to cognitive approaches • Sexual risk in the context of the HIV epidemic is about complexity, about limitations of self-efficacy over sexual relationships, about lack of resources, about marginalisation. • Risk is continuous and complex. Simple concepts of Behaviour Change - ‘ABCs’ hide, this complexity because they focus on the individual: • Abstinence (rational control over sexual desire)– but partner may pressurise • Faithfulness (at best, we can control ourselves)– but partner behaviour cannot be controlled• Condom use (negotiated, technical)– but correct and consistent use not always easy• Partner reduction (number of partners can be controlled)– need for affirmation, love, pleasure in contexts where separated from partners or alone

16. Cognitive approach is dominant in HIV/AIDS campaigns • Most campaigns use mass media • Limitation is that mass media is linear, top down, centralised • Mass media audiences are homogenised - mass media cannot easily adapt to diversity • Communication is broken down into simple messages and imperatives or ‘orders’ • Follow a ‘propaganda’ model, and assume direct causal relationship between knowledge and action

17. HIV/AIDS campaign contexts • HIV/AIDS campaigns are formal organised activities, typically utilising various forms of communication to achieve objectives related to prevention, care, treatment, support and rights • Campaigns represent only one element of the multi-layered discourses that occur in relation to HIV/AIDS • Campaigns contribute to the stimulating individual response, but:- there may be contradictions between campaigns- may contradict regimes of knowledge (eg. Concepts of disease; non-biomedical belief systems; cultural practices; faith-based constructions of the epidemic; fear; stigma)- have a relative meaning in comparison to individual engagement with the epidemic (eg. Being HIV positive, knowing people who have died, volunteering)

18. Communication exposure • HIV/AIDS communication occurs in various contexts:• Mass media, as a product of purposive HIV/AIDS campaigns (TV, Radio, Print, Outdoor, Electronic)• Mass media, unrelated or indirectly related to purposive campaigns: eg. In news, drama, documentaries, features talk shows, newspaper columns• Small media: eg. Leaflets, posters• Events: eg. Plays, rallys, story-telling• Icons, artifacts: Red ribbon, AIDS quilts, artworks – Policy discourses: eg. conferences, workshops – Public relations discourses: eg: press releases, anouncements, launches – Structured, interactive: eg. Counselling – Interpersonal: eg. Conversations, arguments

19. Mass media campaign examples • Number of HIV/AIDS campaigns in South Africa the utilise mass media, and expanded strategies • Integrated model - Soul city (www.soulcity.org.za) • Theorised approach combined with non-didactic model - Tsha Tsha (www.cadre.org.za) • Claims making and rhetoric combined with integration of youth as consumers (www.lovelife.org.za) • Incremental impacts can be demonstrated through evaluations, but massive short-term impacts can only be achieved through a complex of interventions and community-led response

20. Present emphasis - ABC (limits) A range of important prevention strategies are overlooked by an over-emphasis on ‘ABC’ and sexual behaviour: • Prevention of mother-to-child HIV transmission (PMTCT) • Prevention of HIV following rape through post- exposure prophylaxis (PEP) • Prevention of HIV infection through PEP following occupational or other exposure • Prevention of HIV through detecting and treating STIs • Prevention of HIV through addressing gender disempowerment, sexual violence and child sexual abuse • Prevention of HIV through addressing abuses of institutionalised forms of power (e.g. teachers, police, prisons) • Prevention of HIV through addressing economic and structural inequalities

21. Limits of ABC • HIV prevention through ‘universal precautions’ in healthcare and other settings. Includes exposure to patients and healthcare workers in health care settings (unsterile instruments, dental care, expressed breastmilk) • Risks of breastfeeding and shared breastfeeding • HIV prevention through avoiding injecting drugs/needle sharing • Unsterile instruments for tattooing • Emphasis on generalised risk – overlooks the importance of addressing high-risk contexts (sex work, mobile forms of employment, migration, informal urbanisation, gay men)

22. Horizontal and grassroots forms of communication overlooked • Global emphasis on top-down models but grassroots, community-led approaches that use horizontal communication and organisation have been overlooked and marginalised (constructivist and humanist) • Gay men in the US in the 1980s mobilised around the death of friends and leaders - HIV response included closing down gay bath houses, buddy support to people who were ill, condom distribution, political mobilisation and action, counselling and testing, aesthetic responses • Communities in Uganda mobilised around care, focused on importance of partner reduction, openness • Need to reawaken community action models, yet currently funding is highly centralised, models of response don’t foster community action

23. Need to think about epidemiological drivers of the epidemic • – Early sexual debut– Age differentials between partners– Multiple partners– Coercion (as a product of power differentials)– Violence (rape, statutory rape) • Need to look at vulnerability– Specific risks to young females– Children affected by HIV/AIDS in their families (orphaning)– Poor promotion of grants and assistance to vulnerable youth– Inadequate promotion of rights and legal framework– Little emphasis on young PLHA • Contexts of risk– mobility– urbanisation and informal settlement

24. Conclusions • Severe epidemic is very difficult to recover from • Prevention needs to be linked to treatment, care, support and rights • Community mobilisation a key model - need to move beyond top-down approaches • Global and local funding models need to be revised to support community response • National leadership is important, but local leadership more so